O ne of your patients comes to you with a corneal abrasion she got while on vacation. It seems she was posing for a photo when the exotic bird she was holding suddenly scratched her right eye. In 2013, using International Classification of Disease – 9th Edition coding, you would simply use the code for corneal abrasion. Starting October 1, 2014, however, your practice will have to select from the following ICD-10 codes: contusion of eyelid and periocular area (S00.1); unspecified injury of right eye and orbit (S05.91); abrasion of eyelid and periocular area (S00.21); abrasion of right eyelid and periocular area, initial encounter (S00.211A); struck by parrot (W61.02xA); struck by macaw (W61.12xA); struck by other psittacines (W61.22xA); or struck by duck (W61.62xA). Though apparently fantastical, the codes are real, and San Bernardino, Calif., consultant Kevin Corcoran, an expert on ophthalmic coding, uses this example when teaching his course on ICD-10, noting that it gives professionals a feel for what’s coming. (Incidentally, S00.211A and W61.22xA are the correct answers.) “ICD-10 requires a lot more detail from the physician and the biller than they had to provide before,” he says. It turns out this added detail is the tip of the iceberg when it comes to understanding ICD-10.
In this article, we’ll take a look at how ICD-10 requirements are going to affect how you document a patient encounter, show how the new coding process differs from ICD-9 and decipher some of the new coding language for common ophthalmic patient presentations, so your practice can hit the ground running next October.
ICD-10 is a coding standard that emphasizes specificity in documenting a patient’s visit, so much so that the codes in the new book number approximately 69,000. This is a big leap from the 14,000 codes used by ICD-9. “It stems from the fact that coding is going to be more granular and detailed,” says Lisa Gallagher, vice president of technology solutions at the Healthcare Information and Management Systems Society, a non-profit group that seeks to improve health care through the use of computer systems. “With more information, we’ll be able to perform better analytics in terms of the quality of care and population health. With ICD-10, the patient also gets an accurate diagnosis with accurate documentation that will lead to proper payment for the provider.”
Mr. Corcoran says there are several key reasons why ICD-9 is on the way out. “First and foremost, it’s a pretty old system,” he says. “It’s more than 30 years old. Also, some of the language and terms used in ICD-9 aren’t used anymore—a good amount of medical practice has moved on in the past 30 years. Finally, ICD-9 doesn’t offer enough detail.”
As to why the extra details are important, Mr. Corcoran offers the following example. “Say an elderly lady, 80, comes into your office with a black eye, a bump on her head and decreased vision,” he says. “She tells you that she was driving, noting she doesn’t see too well anymore, and ran into the back of the car in front of her, causing her to hit her head on the steering wheel. Upon examination, you find she’s now got traumatic cataracts that are hindering her ability to perform activities of daily living such as driving, and inform her that she needs surgery. In 2013, you would have looked at her cataracts, billed Medicare—probably using 366.16 (nuclear cataract)—and, since you didn’t specify it was incidental to an auto accident, would get paid by the government health program. But in ICD-10, there is a code ‘V43 (struck by automobile),’ which would say to the payor, ‘This was the result of a motor vehicle accident and therefore should be covered by auto insurance—not Medicare.’ ICD-10 turns doctors into this great big reporting system, and third-party payors benefit from it.
“It’s important to note that you can only code what’s in the medical record,” Mr. Corcoran continues. “With ICD-10, the medical record needs to be considerably more precise, and probably longer than it’s been in the past, just to be able to code it. When Australia and New Zealand started implementing ICD-10 several years back, more than half of the charts weren’t codeable. The reason was that, in order to use the ICD-10 coding system, physicians needed more precision in their descriptions. So, if a doctor simply writes, ‘cataract,’ it cannot be coded.”
One of the unintended consequences of this hyper-specificity, and which may hit some physicians where they live, is that practices will no longer be able to use the so-called superbill after an exam, which some doctors use as a “cheat sheet” for the codes they need. There are simply too many possible codes to fit on a sheet of paper. “Right now, a superbill is not going to be provided [with ICD-10],” says Ms. Gallagher. “The set of codes in totality is too massive.” A computer program may help doctors find the right codes—depending on how detailed their documentation is—but, at least in the initial period of ICD-10 adoption, a program may not give you all the codes. For this reason, ophthalmologists and practices who get to know the language of ICD-10, such as how it assigns ophthalmic codes to exam notes and the special terms it uses, will find they have a leg up when documenting their patient encounters and making sure their claims aren’t rejected.
It turns out that, in addition to understanding a new coding system, users of ICD-10 also need to know how to actually read the book, as it uses its own set of terms that may have different meanings than someone is used to. Here are tips for using the book and finding the right codes.
• Know the terms. “The terminology conventions used in the book influence how you use it,” says Mr. Corcoran. “Unfortunately, you can’t use the book like a ZIP code directory—you have to know how to read it.”
One term used often in the book that has the potential to confuse a user is the word “excludes,” since it has two meanings in the ICD-10 world. “ ‘Excludes’ in simple English means to prevent from being a part of a group,” says Mr. Corcoran. “However, in the ICD-10 book, it’s used two ways: Excludes 1 and Excludes 2. In the book, the terms actually have very different meanings. Excludes 1 means two codes are incompatible and cannot be used together on a claim. For example, you’ll notice that the code for blepharitis, H01.0, comes with ‘Excludes 1: blepharoconjunctivitis,’ meaning you can’t code them both together.
“However, Excludes 2 is different,” Mr. Corcoran continues. “It means that another code isn’t included with the particular code you’re looking at but it can coexist at the same time in the same patient. So the code for chalazion (H00.1) has the note ‘Excludes 2: infected meibomian gland,’ since it’s possible for someone to have both conditions concurrently.”
The word “and” also has an unexpected meaning in ICD-10; it means “and/or,” which, unfortunately, is exactly the opposite of the generally understood meaning of the word. “So, if you just flipped open the book without bothering to learn its nomenclature and construction and made an assumption about what the word ‘and’ meant, you’d be wrong,” says Mr. Corcoran.
ICD-10 also makes a point of specifying laterality in its codes, something that was absent in ICD-9. Here’s how it codes laterality:
• 1 is the right eye;
• 2 is the left;
• 3 indicates bilaterality; and
• 9 means the side is unspecified.
For certain diagnoses, ICD-10 also requires that a seventh digit representing the severity of the condition be coded as well, most notably glaucoma:
• 1 represents mild disease;
• 2 is moderate;
• 3 is severe;
• 0 is unspecified; and
• 4 means it is indeterminate.
• Use all the chapters. The ICD-10 book has 21 chapters versus ICD-9’s 17, and physicians have to be ready to use any of them for a given patient. “You can’t just learn the eye chapter—Chapter 7, with codes beginning with H—and throw away the others,” says Mr. Corcoran. “For instance, if your patient has a diabetic eye condition you won’t find it in the eye chapter. Instead, you’ll find it in the chapter on the endocrine system, Chapter 4. The same with shingles; though shingles has ocular implications, if you looked in the eye chapter you wouldn’t find it. You have to go to Chapter 12: Diseases of the Skin, to code ocular complications of shingles.”
• Dig for GEMs. One of the aids the ICD-10 creators have provided for finding a proper code is known as General Equivalence Mapping files. These are software-based conversion tables that allow you to enter in an ICD-9 code and receive a general idea of the coding area in the ICD-10 manual where the appropriate new code or codes might be.
For instance, using the corneal abrasion example from earlier, entering the ICD-9 corneal abrasion code, 918.1, into a GEM converter would give you the ICD-10 code S05.00xA. Here, the letter “S” represents the chapter on injury or poisoning from external sources. You will then have to dig deeper in order to properly code the injury. So, in essence, the GEM will get you in the right neighborhood but you’ve still got to find the exact house. “Is the GEM a perfect match?” asks Mr. Corcoran. “Sadly, no. It’s better than nothing, though, and will get you in the vicinity of the right answer.” A good GEM converter can be found on the website of the American Academy of Professional Coders at
Common Coding Examples
To help get a feel for some common diseases that crop up in the ophthalmologist’s office, here are several examples provided by Mr. Corcoran that are among the many he covers in his ICD-10 training course:
• Corneal ulcer. A patient presents with a central ulcer. In ICD-9 you’d note that it was a central ulcer, ignoring laterality, and use code 370.03. In ICD-10, however, you have these choices: H16.011 (central corneal ulcer, right eye); H16.012 (central corneal ulcer, left); H16.013 (central corneal ulcer, bilateral); and H16.019 (central corneal ulcer, unspecified).
• Cataract. When a patient is diagnosed with a nuclear cataract and the GEM file is used, it finds the ICD-10 code H25.819 (combined forms of age-related cataract, unspecified eye). “Might we probably know more than that about the patient?” muses Mr. Corcoran. “In terms of laterality, yes. But, now that we’re in the ballpark, after looking at the actual section under H25.819, we see the real code will be H25.811, H25.812, or H25.813. It won’t actually be H25.819 (unspecified).”
A practice may also see the occasional Flomax patient who needs mechanical dilation of the pupil during surgery. In the new coding standard, certain drugs have their own codes that need to be entered in the record for certain diagnoses. In this case, the coding would be H25.11 (age-related nuclear cataract, right eye), H21.81 (IFIS) and the code for the drug T44.6x5A (tamsulosin anti-adrenergic use).
• Diabetic eye disease. In some cases, ICD-10 creates just one code where ICD-9 used two, such as in the case of proliferative diabetic retinopathy. In ICD-9, the codes would be 250.52 (uncontrolled Type 2 diabetic with ophthalmic manifestations) and 362.02 (proliferative diabetic retinopathy). In ICD-10, however, you use one code for this patient: E11.359 (Type 2 diabetes mellitus with proliferative diabetic retinopathy without macular edema).
Another new concept in ICD-10 is the need to note the patient’s use of insulin with code Z79.4 (long term current use of insulin). “This is significant because the long-term use of insulin matters in public health,” explains Mr. Corcoran. “If someone begins taking insulin early in life, they might be a big burden on the health-care system for the rest of their lives.”
• Glaucoma. Another example involves a patient who presents with uncontrolled, chronic open-angle glaucoma OU with severe visual field loss in the right eye and moderate field loss in the left. In ICD-9, the codes would be 365.11 (POAG, chronic simple glaucoma) and 365.73 (severe glaucoma).
In ICD-10, the proper codes would be H40.11x3 (severe glaucoma, right eye), H40.11x2 (moderate glaucoma, left eye) and the practice has the option of also including H53.40 (unspecified visual field defects) if it wanted to provide more information.
• Age-related macular degeneration. A patient you’ve been following for AMD presents with severe vision loss in her right eye. She admits to being a smoker. You find exudative AMD in the right eye and dry AMD in the left. You treat the right eye that day with an injection of bevacizumab.
To code this particular patient, you would use the codes H35.32 (exudative AMD), H35.31 (non-exudative AMD) and would also have to note Z72.0 (tobacco use). One thing to note is that there is no laterality when coding AMD.
Though ICD-10 will pose documentation, coding and technological challenges as practices overhaul their systems to accommodate the new system, one thing is clear: It won’t be postponed and will be required for reimbursement come October 2014. “CMS informs us that we need to reinforce the message that the deadline is not going to change,” says HIMSS’ Ms. Gallagher. “It’s come down from the secretary of the Department of Health and Human Services that it’s not going to be delayed. They’re sticking to the deadline.”